EHR-Integrated Patient-Reported Outcomes in Ambulatory Oncology: A Critical Opportunity for Timely and Targeted Palliative Care
Authors: Patricia I. Moreno, Frank J. Penedo, Felicia M. Knaul, Carina Oltmann, Michael T. Huber, Mariana Khawand-Azoulai
Journal: Journal of the National Comprehensive Cancer Network (2023)

T he aim of systematic symptom screening and monitoring using patient-reported outcomes (PROs) is to collect actionable data and provide responsive care that is centered around patients' needs.2][3][4] As a result, there has been a significant interest in both incorporating these assessments as standard of care and integrating them in the electronic health record (EHR) so that results populate in real-time and facilitate care coordination.A recent study by our team demonstrates initial feasibility of EHR-integrated PROs among diverse Spanish and English speakers and provides a framework for implementation using the Exploration, Preparation, Implementation, Sustainment (EPIS) model. 5However, despite the growing movement to implement routine EHR-integrated assessments of PROs in oncology, there has been little consideration of how these assessments should interface with palliative care and how they can be leveraged to deploy timely referrals for the patients who need them most during cancer treatment and across the survivorship continuum. 6lthough outdated models of care only incorporated palliative care at end of life after disease-modifying treatment was no longer available, newer evidencebased models emphasize its integration earlier in the disease course in the ambulatory setting to proactively prevent unnecessary suffering. 6Robust evidence from randomized controlled trials (RCTs) demonstrates that early integration of specialty palliative care (ie, interdisciplinary teams led by board-certified palliative medicine physicians) for patients with advanced cancer improves outcomes throughout the disease course by reducing symptom burden, improving HRQoL and satisfaction with care, and increasing advance care planning. 7-9Furthermore, guidelines from NCCN and ASCO state that palliative care needs should be continuously assessed in all patients with cancer, regardless of disease stage, to ensure prompt referrals to specialty palliative care for patients with palliative care needs, such as high symptom burden and/or unmet physical, psychosocial, and existential care needs. Current State of Palliative Care Research and PracticeDespite the benefits of early integration of palliative care, many patients still only receive palliative care late in the disease continuum, at or near end of life, or not at all.Furthermore, RCTs examining the efficacy of palliative care have typically tested a model of care that uniformly integrates palliative care within 3 months of diagnosis for individuals with advanced cancer and has a prescriptive follow-up schedule (eg, at least one outpatient palliative care appointment per month).Importantly, an approach based solely on diagnosis fails to account for heterogeneity across patients and the need to deploy care that is responsive to their unique symptom profiles and supportive care needs.The well-documented growing shortage of palliative care